2. Answers

1. Correct Answer D.

A. Although the patient seems to have some sort of chronic pain issue, increased NSAID use is commonly associated with gastric ulcers. Allowing the patient unlimited NSAID use would predispose him to peptic ulcer disesase. If the patient did develop these ulcers, the treatment of choice would be to stop the NSAID and start a PPI.

D. The patient is using medications that are commonly used to treat both DM and HTN, but due to his increased Cr and DM some changes are required. If a patient does not have any comorbidity than HCTZ is the first line treatment for HTN, but with DM ACEIs are considered frontline medications as it has been linked to the slowed progression of diabetic related kidney damage which is seen with proteinuria.

Also, with the elevated Cr metformin is contraindicated due to the possible risk of lactic acidosis. An alternative medication such as a sulfonylurea can be used.

A, B, C: The current accepted practice is that it is not acceptable for a physician to be involved in euthanasia. A key point: Euthanasia: Physician initiates and administers the lethal drug. Physican Assisted Suicide: Physician gives the drug to the patient and the patient self-administers the medication. The location of Maryland is stated since Oregon is known to accept euthanasia as legal.

There is no current accepted basis to wait 24 hours then administer euthanasic medications. A patient’s words are a key factor in dealing with end of life care issues, but once again a health care provider should not actively case the death of the patient no matter how willing a patient is. The most logical answers out of the choices is E, to continue supportive treatment.

“The American College of Physicians–American Society of Internal Medicine (ACP–ASIM) does not support the legalization of physician-assisted suicide. The routine practice of physician assisted suicide raises serious ethical and other concerns. Legalization would undermine the patient–physician relationship and the trust necessary to sustain it; alter the medical profession’s role in society; and endanger the value our society places on life, especially on the lives of disabled, incompetent, and vulnerable individuals. The ACP–ASIM remains thoroughly committed to improving care for patients at the end of life”

B: There is mild evidence that CoQ-10 deficiency may be linked with statin-induced rhabdomyolysis. Statins have been been linked to decreasing CoQ-10. The

other listed substances have not been linked to reducing the myopathy. According to the Archives of Neurology:

“In summary, our data suggest that statin drugs may decrease the concentration of CoQ10 in muscle to a modest extent in some patients. Although these data do not support a pathogenic role of CoQ10 deficiency in statin drug–related myopathy, it may be prudent to advocate that patients with statin drug–related myopathy

4. Correct Answer: AA: The traditional method of diagnosisng DM is through an overnight fast and then measuring the blood glucose levels. Below 99 mg/dL is considered normal, 100 – 125 mg/dL is impaired fasting glucose, >126 mg/dL is considered diabetic and a repeat test is indicated to confirm the diagnosis. This is the fasting plasma glucose test (FPT).B. HbA1c is a diagnostic tool usually used to measure the long term glycemic control in an individual. Currently this is not a screening test.C. Random fasting glucose can diagnose DM if the levels are about 200 mg/dL with symptoms of polyuria, polydipsia, or unexplained weight loss. The results can be skewed due to the patient having a recent meal. Abnormal values are confirmed though a FGT or OGTT D. Urine dipstick for glucose indicating glycosuria indicates abnormal glucose levels and further workup is indicated, not the most common method to diagnose patient. E. OGTT: Involves a patient fasting for 8 hr prior to a 75 g oral glucose load, if the 2hr post load glucose is above 200 mg/dL indicate diabetes and repeat test, between 140 – 199 mg/dL indicate impaired glucose tolerance, and below 139 mg/dL indicate normal results. In pregnancy a 100g oral glucose tolerance is used, gestational diabetes mellitus (GDM) can be diagnosed if the fasting glucose is > 95 mg/dL, 1 hr > 180 mg/dL, 2 hr > 155 mg/dL, 3 hr > 140 mg/dL

A. Remember that HIV is a virus that causes AIDS with today’s treatment HIV is becoming a chronic condition. There are several AIDS defining conditions and following HIV viral load with CD4 counts area are part of the management of an HIV positive patient.

B. Classically gp120 is a highly variable glycoprotein that has been the target of vaccine research, but there is no cure or vaccine that has been found for the virus. There is a lot of active research to find a vaccine, a recent study from the the New England Journal of Medicine stated:

“This ALVAC-HIV and AIDSVAX B/E vaccine regimen may reduce the risk of HIV infection in a community-based population with largely heterosexual risk. Vaccination did not affect the viral load or CD4+ count in subjects with HIV infection. Although the results show only a modest benefit, they offer insight for future research.

Source: Vaccination with ALVAC and AIDSVAX to Prevent HIV-1 Infection in Thailand

D. While it is true that HIV is a mandatory reportable disease, it is not the current policy to have a national database of each individual who has the disease. According to the U.S. Department of Health and Human services:

"If your HIV test is positive, the clinic or other testing site will report the results to your state health department. They do this so that public health officials can monitor what’s happening with the HIV epidemic in your city and state. (It’s important for them to know this, because Federal and state funding for HIV/AIDS services is often targeted to areas where the epidemic is strongest.)

Your state health department will then remove all of your personal information (name, address, etc.) from your test results and send the information to the U.S. Centers for Disease Control and Prevention (CDC). CDC is the Federal agency responsible for tracking national public health trends. CDC does not share this information with anyone else, including insurance companies."

E. Federal regulation allows for individuals under certain circumstances to a leave from work, as per the Federal Medical Leave Act of 1993:

“Applies to private-sector employers with 50 or more employees within 75 miles of the work site. If you are eligible, you can take leave for serious medical conditions or to provide care for an immediate family member with a serious medical condition, including HIV/AIDS. You are entitled to a total of 12 weeks of job-protected, unpaid leave during any 12-month period.”

Source: The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation,and Treatment of High Blood Pressure

http://www.nhlbi.nih.gov/guidelines/hypertension/express.pdf

7. Correct Answer A

A. The U.S. Preventive Services Task Force (USPSTF) concludes that the evidence is insufficient to recommend for or against screening asymptomatic persons for lung cancer with either low dose computerized tomography (LDCT), chest x-ray (CXR), sputum cytology, or a combination of these tests.

B. The USPSTF recommends screening for colorectal cancer (CRC) using fecal occult blood testing, sigmoidoscopy, or colonoscopy, in adults, beginning at age 50 years and continuing until age 75 years. The risks and benefits of these screening methods vary.

Grade: A Recommendation.

The USPSTF recommends against routine screening for colorectal cancer in adults age 76 to 85 years. There may be considerations that support colorectal cancer screening in an individual patient.

Grade: C Recommendation.

The USPSTF recommends against screening for colorectal cancer in adults older than age 85 years.

Grade: D Recommendation.

The USPSTF concludes that the evidence is insufficient to assess the benefits and harms of computed tomographic colonography and fecal DNA testing as screening modalities for colorectal cancer.

The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms.